Clinical P RACTIC E Interdental Papilla Reconstruction Combining Periodontal and Orthodontic Therapy in Adult Periodontal Patients: A Case Report Contact Author Fernando Inocencio, DDS, Dip Ortho; Harinder S. Sandhu, DDS, PhD, Dip Perio Dr. Sandhu Email: harinder.sandhu@ schulich.uwo.ca ABSTRACT Migration of maxillary anterior teeth because of the loss of periodontal support can alter the appearance of the esthetic zone. The loss of contacts between adjacent teeth results in the recession of interdental papillae. To restore sustainable periodontal health and the normal, esthetic appearance of a healthy 37-year-old woman with general- ized advanced chronic periodontitis in the maxillary arch, a combined periodontal and orthodontic technique was used. This approach resulted in stable periodontium and an esthetically pleasing appearance of the maxillary anterior area. For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-74/issue-6/531.html athologic migration of maxillary anterior immediately by orthodontic treatment to re- teeth because of a loss of periodontal duce the infrabony defects caused by the in- support is very common.1 This migra- trusion and lateral movement of teeth into the P 2–4 tion can result in the extrusion of teeth, loss defect.1–3,20–23 These clinical techniques may of contact points, missing papillae and poor also help to re-establish the contact points, 5–7 appearance of the esthetic zone. In the ab- reduce the distance between the contact point sence of contacts between the adjacent teeth, and the alveolar crest and re-form the inter- papillae recede. It has been proposed that the dental papillae.5–8,18,22,24–26 distance from the contact point to the alveolar This paper is the initial report of an inter- crest is at least partially indicative of the pres- disciplinary investigation into the outcome of ence of interdental papillae.8 treatment designed to enhance the prognosis Several periodontal surgical techniques of periodontally involved teeth and to improve have been proposed to recreate the missing papillae5,7,9–17; however, predictable results have the appearance of the esthetic zone. not yet been achieved.18 In cases of loss of peri- odontal support and shifting teeth, a multi- Case Report disciplinary treatment approach with esthetic A healthy 37-year-old woman who was periodontal surgery is required to eliminate a smoker sought treatment of her shifting periodontal inflammation without loss of soft maxillary teeth and closure of diastemas tissue.4,5,7,18,19 This surgery should be followed (Fig. 1). A diagnosis of generalized advanced JCDA • www.cda-adc.ca/jcda • July/August 2008, Vol. 74, No. 6 • 531 ––– Sandhu ––– Figure 1: Initial intraoral photographs showing generalized spacing and absence of papillae in the upper anterior segment. Figure 2: Initial radiographs revealed the presence of bony defects between the central incisors and the lateral incisors and canines. chronic periodontitis in the maxillary arch was made. Upper brackets on the incisors and canines, as well Undergoing smoking cessation counselling helped the as direct bonding tubes on the first molars, were bonded, patient quit smoking; she has been tobacco-free since the starting with a nickel-titanium 0.016 archwire for in- surgical treatment. itial alignment, followed by nickel-titanium 0.018, nickel- After the initial sanative phase, osseous surgery for titanium 0.018 × 0.025 and stainless steel 0.018 × 0.025 pocket reduction was completed in sextant 1 and sex- archwires. Closing the space by moving the central and tant 3. To avoid maxillary anterior soft-tissue loss, papilla lateral incisors into the bony defects was started with an preservation flap surgery was done.12,13 This procedure elastomeric power chain. allowed access to the infrabony defects (Fig. 2) for de- Because of the reduction in the overjet, lower brackets bridement without loss of papillae. No adjunct guided that mirrored the upper ones were bonded to anchor the closure of the space by means of the mesialization tissue regeneration was attempted. of the upper posterior segments with Class III elastics. The patient was followed 6 weeks for postoperative Some intrusion of the upper incisors was intended, but it care and was referred to an orthodontist for further was limited because of the shallow overbite. During the orthodontic management of the diastemas and missing orthodontic procedures, oral hygiene maintenance was papillae. The patient was seen every 3 months for peri- done every 3 months. odontal maintenance during her orthodontic treatment. After the space was closed, the esthetic appearance Periodontal pocket depths and clinical attachment levels of the papillae was significantly improved, resulting in before and after periodontal treatment, and after ortho- a normal appearance of the whole anterior segment dontic treatment are shown in Table 1. (Fig. 3). Periapical radiographs showed improvement at Although some proinclination of the incisors was the level of the bone crest between the central incisors present, the relatively shallow overjet and overbite made and between the lateral incisors and canines (Fig. 4). room for the intrusion and retrusion of the incisor seg- Resin-bonded fixed retention was established after the ment very limited. appliances were debonded. 532 JCDA • www.cda-adc.ca/jcda • July/August 2008, Vol. 74, No. 6 • ––– Papilla Reconstruction ––– Figure 3: Post-treatment photographs showing proper proximal contacts and improved appearance of the papillae. Figure 4: Post-treatment radiographs showing a significant reduction of the bony defects after space closure. Table 1 Clinical measurements (mm) of lateral incisors before treatment, after periodontal treatment and after orthodontic treatment Probing pocket depth (mm) Clinical attachment level (mm) After After After After Before periodontal orthodontic Before periodontal orthodontic Incisors treatment treatment treatment treatment treatment treatment Right lateral incisor Mesiobuccal 3 3 2 3 3 2 Buccal 2 2 2 2 2 2 Distobuccal 7 4 2 7 4 2 Distolingual 7 4 3 4 3 3 Lingual 5 2 2 5 2 2 Mesiolingual 3 2 2 3 2 2 Left lateral incisor Mesiobuccal 3 2 2 3 2 2 Buccal 2 2 2 2 2 2 Distobuccal 4 4 2 4 4 2 Distolingual 6 2 2 6 2 2 Lingual 2 2 2 2 2 2 Mesiolingual 3 2 2 3 2 2 JCDA • www.cda-adc.ca/jcda • July/August 2008, Vol. 74, No. 6 • 533 ––– Sandhu ––– Discussion minor intrusion achieved a healthy stable periodontium and significantly improved the appearance of the esthetic Periodontic plastic surgical procedures have tre- a mendously improved with the use of microscopes and zone. microsurgical instruments. Although many investiga- tions9–11,14,16,17,26,27 have proposed procedures for recon- THE AUTHORS structing the papillae, predictable results have not yet 18 been achieved because of a variety of factors. Infrabony Dr. Inocencio is an assistant professor in the division of defects can be treated by extrusion20 and intrusion5,7,19 orthodontics and pediatric dentistry, Schulich School of of teeth, bodily movement of the teeth into the bony Medicine and Dentistry, University of Western Ontario, London, Ontario. defects21,22 and guided tissue regeneration.7 For our pa- tient, we used a modified papilla preservation technique, followed by orthodontic mesialization of the posterior Dr. Sandhu is a professor in the division of periodontics, segments and minor intrusion of the maxillary anterior Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario. segment. Our patient’s occlusal conditions limited the amount of intrusion feasible and may have had an impact Correspondence to: Dr. Harinder S. Sandhu, Schulich School of Medicine on the final results. and Dentistry, University of Western Ontario, Dental Sciences Building, With this combined periodontal and orthodontic Room 1003, London, ON N6A 5C1. treatment, stable periodontal health was achieved. Pocket Acknowledgments: We would like to thank Meghan Perinpanayagam for depth was reduced and the level of clinical attachment her assistance in the preparation of this manuscript. improved. Results of a radiographic survey showed that The authors have no declared financial interests. the infrabony defects were at least partially healed and the height of the alveolar crest around the lateral incisors in- This article has been peer reviewed. creased. These results were obtained without the addition of any regenerative materials. With the re-establishment References 1. Steffensen B, Storey AT. Orthodontic intrusive forces in the treatment of contact points between the central and lateral incisors of periodontally compromised incisors: a case report. Int J Periodontics and the lateral incisors and canines, the interdental pap- Restorative Dent 1993; 13(5):433–41. illae returned to their proper contours and almost filled 2. Melsen B, Agerbaek N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial the interdental spaces. These clinical improvements cre- Orthop 1988; 94(2):104–16. ated an esthetic appearance free from receded papillae 3. Melsen B, Agerbaek N, Markenstam G. Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dentofacial Orthop 1989; and diastemas. For our patient, the reduction in pocket 96(3):232–41. depth, gain in clinical attachment level and reduction in 4. Melsen B, Agerbaek N. Orthodontics as an adjunct to rehabilitation. mobility were consistent with the elimination of inflam- Periodontol 2000 1994; 4:148–59. mation and improved home care.28 5. Cardaropoli D, Re S, Corrente G, Abundo R. Reconstruction of the maxil- lary midline papilla following a combined orthodontic-periodontic treatment Radiographic reduction of our patient’s infrabony in adult periodontal patients. J Clin Periodontol 2004; 31(2):79–84. defects, especially around the lateral incisors, was con- 6. Cardaropoli D, Re S, Corrente G. The Papilla Presence Index (PPI): a new 5,7,19,21 system to assess interproximal papillary levels.